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Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiteraturePiacentini Giacomo1, Spinoglio Luca1, Beltrami Riccardo1, Silvestri Maurizio1 and Piacentini Cesare2
1Department of Internal Medicine and Therapeutics, Private Practice, University of Pavia, Pavia, Italy2Department of Dentistry, University of Pavia, Italy*Corresponding author: Silvestri Maurizio, Department of Internal Medicine and Therapeutics, Private Practice, University of Pavia, Pavia, Italy, Tel: +39 333 2177776;E-mail: [email protected]
Received date: July 09, 2018; Accepted date: August 03, 2018; Published date: August 08, 2018
Copyright: ©2018 Giacomo P, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Purpose: To evaluate the scientific evidence on the efficacy of non-surgical treatments of Peri-implantitis.
Material and methods: The effect of mechanical debridement associated with adjunctive measures wascompared with mechanical debridement alone on the following outcomes: implant failure, radiographic margin bonelevel, complications and Peri-implantitis recurrence, changes in probing pocket depth, clinical attachment level andbleeding on probing. A search in MEDLINE-PubMed, Embase and the Cochrane Central Register of controlled trials(CENTRAL) was conducted up to February 2017. Randomized controlled trials (RCT) reporting data on non-surgicalprofessional treatments of Peri-implantitis including at least 10 patients in good systemic conditions were selectedfor the analysis.
Results: The screening of titles and abstracts resulted in 15 publications meeting the eligibility criteria. Thefollow-up ranged between 3 and 12 months and the study population varied between 10 and 63 patients. Therapiesutilized in the included studies were antiseptics, local and systemic antibiotics, Er:YAG, ND:YAG and diode laser,courettes and ultrasonic devices. One study presented low risk of bias, while 11 studies were with a high risk of bias.No implant failure was reported. One study reported about complications related to therapies employed. Diseaserecurrence was found in two of the included papers.
One study provided available data on radiographic bone level changes, but no statistically significant differenceswere found between test and control group at the end of the follow-up.
Conclusions: Non-surgical therapy of Peri-implantitis seems to have a limited efficacy. Only the use of systemicazithromycin associated to mechanical debridement can give better clinical outcomes, indeed in the study of Gomi etal. was reported a greater reduction of 0.96 ± 0.4 mm in the test group compared with the data of the control groupafter 1 year of follow up.
Keywords: Peri-implantitis; Therapy; Non-surgical; Systematicreview
IntroductionThe use of dental implants for replacement of missing teeth
represents a widely accepted treatment option in oral rehabilitation.Implants have shown satisfactory results in rehabilitation of patient’sfunction and long-term survival rates of approximately 89% after 10years [1]. Nevertheless dental implants are not free of complicationsand long-term prognosis can be altered by technical difficulties orinfections [2]. Peri-implant disease can be classified as peri-implantmucositis and peri-implantitis. Whereas peri-implant mucositis ischaracterized by a reversible inflammation limited to the peri-implantmucosa, peri-implantitis is a non-reversible inflammation of peri-implant tissues leading to a reduction of the peri-implant bone level[3]. If no successful treatment is performed, peri-implantitis can bringto implant loss [4-6].
Peri-implant disease is an important pathological entity due to itsprevalence and incidence. Peri-implant mucositis has been reported to
affect 80% of the subjects and 50% of the implants, while peri-implantitis was identified in percentages ranging between 28% and56% of subjects and 12% and 43% of implant sites, respectively [7].
Peri-implant disease is infectious in nature and the main etiologicalfactor is the development of a bacterial biofilm on implant surface [8].After being inserted in bone, the supragingival aspect of implantsurface is covered by an organic layer formed by proteins,glycoproteins and lipids and this represents the stratum on whichbacterial colonization occurs [9].
A study on composition of the microbiota in peri-implantitisrevealed the presence of periodontopathogen microorganisms asPrevotella intermedia, Porphyromonas gingivalis, Treponema denticolaand Aggregatibacter actinomycetemcomitans [10]. On the other hand,a recent review concluded that even if the microbiota associated withperi-implant disease is similar to that of chronic periodontitis, thereare cases specifically associated with other bacterial species, asPeptostreptococcus spp. or Staphylococcus spp. [11].
Although bacterial contamination is the primary etiological factor,there are multiple risk indicators that must be taken into account in
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ISSN: 2155-6148
Journal of Anesthesia and ClinicalResearch Giacomo et al., J Anesth Clin Res 2018, 9:8
DOI: 10.4172/2155-6148.1000850
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Volume 9 • Issue 8 • 1000850
peri-implant disease manifestation and progression, as a previoushistory of periodontitis and cigarettes smoking [3]. Further factors, asthe influence of keratinized mucosa, genetic traits and implant surfaceare under investigation [12].
The diagnosis of peri-implantitis is based on clinical andradiographic findings. Changes in probing depth associated withbleeding or suppuration on probing indicate the presence of peri-implant inflammation and radiographs are used to confirm peri-implant bone loss [13,14].
The target for the treatment of peri-implant disease is the removal ofbacterial biofilm and the disinfection of implant surface. However thepresence of screw threads and surface roughness makes implantdecontamination a difficult issue. Non-surgical treatment is the first-line intervention to control peri-implant disease.
Different studies on non-surgical approach have reported promisingresults for inflammation control in terms of reduction of bleeding onprobing but whilst peri-implant mucositis can completely heal, thereare unpredictable results for the treatment of peri-implantitis [3].
The aim of the present systematic review was to evaluate all thescientific evidence on non-surgical treatment of peri-implantitis and tosystematically assess the efficacy of this therapy on implant failure,radiographic margin bone level, complications and peri-implantitisrecurrence.
Materials and MethodsThe present systematic review was developed and conducted
following the PRISMA statement [15] and, before the start; a protocolwas set including these definitions [16].
Focused question
Study population
Types of intervention
Types of comparisons
Outcome
Search strategy
Eligibility criteria for study inclusion
Outcome measures
Screening methods and data extraction
Quality assessment and data synthesis
Assessment of heterogeneity and drawing of conclusions
Focused questionThe focused question was: “In patients with diagnosed peri-
implantitis what are the most effective non-surgical treatment onimplant failure, changes in radiographic margin bone level,complications and peri-implantitis recurrence?”
Population, interventions and outcomeThe population of interest for this review was represented by
humans in good systemic conditions, older than 18 years with at leastone implant with diagnosed peri-implantitis.
The definitions used for peri-implantitis were: “plaque-inducedprogressive marginal bone loss observed on radiographs with clinicalsigns of infection of the peri-implant soft tissues” [17] for clinical signand “detectable bone loss from 1-year examination and bone level loss≥ 1.8 mm” [18] for radiographic evaluation.
The interventions examined were any non-surgical mechanicaltherapy for biofilm debridement in association or not with anyadjunctive measure.
The primary outcomes analyzed were drawn from a previoussystematic review of Cochrane Collaboration Group [17].
- Implant failure defined as implant mobility of a previouslyclinically osteointegrated implant and removal of non-mobile implantsbecause of progressive marginal bone loss or infection.
- Radiographic margin bone level measured as the change on intra-oral radiographs taken with paralleling technique.
- Complications and side effects.
- Peri-implantitis recurrence.
The secondary outcomes were probing pocket depth (PPD), clinicalattachment level (CAL) and bleeding on probing (BOP).
Search strategyTwo reviewers (GLS and GP) conducted a literature search
independently in three electronic databases: PubMed, Embase andCentral up to and including 10 February 2017. The following keywords and MeSH terms were used:
Population: ("peri implantitis" or periimplantitis or perimplantitis orperi-implantitis or peri-implant* or "peri implant*" or perimplant* orperiimplant* or "Peri-Implantitis" [Mesh]).
Intervention: (Treatment or therapy or prevention or managementor maintenance or "non-surgical" or "Therapeutics" [Mesh] or("Tertiary Prevention" [Mesh] or "Secondary Prevention" [Mesh] or"Primary Prevention" [Mesh]) or "Disease Management" [Mesh])).
In addition, the following journals were hand-searched: Journal ofClinical Periodontology, Journal of Periodontology, Clinical ImplantDentistry, Clinical Oral Implants Research, European Journal of OralImplantology, International Journal of Oral and Maxillofacial Implants,Journal of Oral Implantology, International Journal of Periodonticsand Restorative Dentistry. The reference list of the selected studies wasscanned for cross-references. In addition, a search in the grey literaturewas performed on Opengrey (http://www.opengrey.eu) using thewords “peri-implantitis” and “treatment” for this specific database. If itwas necessary, authors were contacted to provide missing information.There was no language restriction.
Inclusion and exclusion criteriaInclusion criteria used were defined as follows:
• Non-surgical professional treatments of peri-implantitis.
• Randomized controlled trials either split-mouth or parallel groupdesign.
• Patients in good systemic conditions who have ≥ 1 implant withperi-implantitis.
Exclusion criteria were, instead, defined as follows:
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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• Less than 10 patients/group.
Study selectionIn the first stage, two independent reviewers (GLS and GP) screened
titles and abstracts and did the primary search.
The management of the articles was achieved using commerciallyavailable software (Endnote X7, Thomson, London, UK).
Subsequently, the studies that could meet the inclusion criteria andarticles with unclear information in the title and abstract were selectedfor full-text analysis, which was performed independently by the sametwo reviewers (GLS and GP). Any disagreement was discussed with athird member (RB) until consensus was reached.
Finally full-text analysis was performed, excluding the studies thatdid not meet inclusion criteria and the reasons of this choice wererecorded at any step.
In case of discrepancy between the reviewers, disagreements werediscussed with a third person (RB) until the reaching of the consensus.
Data extraction and data analysisData from the studies were extracted by two independent reviewers
(GLS and GP) in specific forms based on type of study design, numberof implants treated, durations of follow-up, dimensions of thepopulations, mean ages, smoking habits, periodontal health, type ofimplants, treatments performed, measurement methods, outcomesevaluated, sites and sources of funding. Any disagreement wasdiscussed with a third reviewer (RB) when necessary.
Authors of the manuscripts were contacted when data wereincomplete or missing. When the results of a study were publishedmore than once, the most complete dataset was included only onetime.
To compare the selected studies, primary and secondary outcomes(probing pocket depth, clinical attachment level and bleeding onprobing) were pooled and analyzed using weighted mean differences(WMD) and 95% confidence intervals.
Data were calculated using commercially available software(STATA® 13, StataCorp LP, and Lakeway Drive, College Station, TX,USA).
Statistical significance was defined as a P-value <0.05.
Quality assessmentThe quality assessment was conducted in duplicate by two reviewers
(RB and GLS). The Cochrane collaboration’s tool for assessing risk ofbias [19] was used to determine the quality of the full-text articlesincluded, performed in two steps.
Firstly it was considered if the studies met the criteria for thefollowing domains:
• Sequence generation. Describe the method used to generate theallocation sequence in sufficient detail to allow an assessment ofwhether it should produce comparable groups.
• Allocation concealment. Describe the method used to conceal theallocation sequence in sufficient detail to determine whetherintervention allocations could have been foreseen in advance of, orduring, enrolment.
• Blinding of participants, personnel and outcome assessors.Describe all measures used, if any, to blind study participants andpersonnel from knowledge of which intervention a participantreceived. Provide any information relating to whether the intendedblinding was effective.
• Incomplete outcome data. Describe the completeness of outcomedata for each main outcome, including attrition and exclusions fromthe analysis. State whether attrition and exclusions were reported, thenumbers in each intervention group (compared with total randomizedparticipants), reasons for attrition/exclusions where reported, and anyre-inclusions in analyses performed by the review authors.
• Selective outcome reporting. State how the possibility of selectiveoutcome reporting was examined by the review authors, and what wasfound.
• Other sources of bias. State any important concerns about bias notaddressed in the other domains in the tool.
Subsequently, a judgement was assigned answering to the previousdomains. An answer “+” indicates a low risk of bias and an answer “-”indicates a high risk of bias. The answer “?” indicates an unclear risk ofbias. Publications were considered as low risk of bias when all the fivecriteria were low.
Articles were considered as high risk of bias if at least two of the fivecriteria were unclear or at least one of the criteria was high or if therandomization was not done in a proper way. When one of the criteriawas unclear, the protocol was considered as unclear risk of bias.
Results
ScreeningThe search strategy returned 4105 results. Of all those, 4103 articles
were considered after duplicates removal. During the first stage ofstudy selection 4080 publications were excluded based on titles andabstracts.
Study Reasons of Exclusion
Bach et al. [20] Lack of data
Javed et al. [21] Mixed mucositis and peri-implantitis
Karimi et al. [22] Mixed mucositis and peri-implantitis
Lerario et al. [23] Mixed mucositis and peri-implantitis
Tang et al. [24] Mixed mucositis and peri-implantitis
Renvert et al. [25] Mixed mucositis and peri-implantitis
Renvert et al. [26] Mixed mucositis and peri-implantitis
Renvert et al. [27] Mixed mucositis and peri-implantitis
Romeo et al. [28] Mixed mucositis and peri-implantitis
Sahm et al. [29] Mixed mucositis and peri-implantitis
Table 1: A total of 10 papers had to be excluded after reading the full-text because they did not fulfill the inclusion criteria of the presentreview.
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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In the second stage, 22 potentially relevant publications wereevaluated. A total of 10 papers had to be excluded after reading thefull-text because they did not fulfill the inclusion criteria of the presentreview (Table 1). The flow diagram describes the results of search
queries (Figure 1). A total of 12 studies were included for the analyses.The pooled analysis comprised 334 patients for 536 implants affectedby peri-implantitis.
Figure 1: The flow diagram describes the results of search queries.
Study population and study designVariables of study population and study design are presented in
Table 2.
The follow-up of the included studies ranged from 3 to 12 months.Three studies presented a split-mouth design with 3 and 6 months offollow-up. Smoking status was reported in 8 studies and ranged from0% to 38% [30,31].
The periodontal status of the involved patients was expressed in 8papers [32-39]. The study population ranged from 10 to 63 subjectsand the number of treated implants ranged between 22 and 100.
Six studies specified the implant surface, which were TPS [31,33,40]and SLA [30,31,33,36,40] and 1 study [35] didn’t treat TPS or HAsurfaces.
In the others six studies, 4 specified only the type of implants used[32,37,38,41] 1 described only the surface as “machined” [34] and thelast one didn’t report anything [39].
Type of intervention and comparisonThe study interventions and comparison were either combined
treatments or treatments alone (Table 2).
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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Therapies employed for mechanical debridement were sonic/ultrasonic scalers [39], plastic/carbon/titanium courettes [30,32,38,39]and the VECTOR® system [32].
Jansaker et al. [37] performed a submucosal mechanicaldebridement with ultrasonic scaler to all patients and then employedChloramine perisolve in test group. VECTOR® system was comparedwith the efficacy of carbon courettes in the study of Karring et al. [32].
To treat the peri-implants infections Schwarz et al. [31,33]performed a professional cleaning with rubber cups and polishingpaste, then then they compared the efficacy of Er:YAG laser withplastic courettes with Chlorhexidine 0.2% irrigations andChlorhexidine 0.2% Gel. Renvert et al. [34] used Er:YAG laser in thetest group and PERIO-FLOW in control group. Bassetti et al. [36] firstof all treat patients with carbon courettes in combination with GlycineAir Powder, then use or Diode Laser or Minocycline HydrochlorideMicrospheres.
Arisan et al. [40] used plastic courettes associated, in test group,with Diode Laser. In the study by Abduljabbar et al. [41] an Nd:YAGlaser was employed as an adjunctive measure to plastic courettes in thetest group. Antibiotics and antiseptics were used as chemical agents fortreatment of peri-implantitis.
In the study by Gomi et al. [39] systemic azithromycin wasprescribed starting 3 days before non-surgical therapy with a doses of500 mg/day for 3 days, in the test group, as an adjunctive measure toultrasonic Scaler with plastic tips and plastic courettes. Büchter et al.[30] subgingival irrigations with 8.5% doxycycline were performed inadjunction of plastic courettes and Chlorhexidine 0.2% irrigations intest group.
Antiseptic therapy was performed using 0%, 1% and 0%, 2%subgingival irrigations in association with mechanical treatments in 4
studies [30,31,33,38] while in one paper 0%, 2% or 1% chlorhexidinegel was applied [31]. In one study [36], 0%, 5% chlorhexidine chipswere employed in association with ultrasonic debridement andcompared with placebo.
John et al. [38] performed a study in which given supramucosal/gingival professional implant/tooth cleaning with rubber cups andpolishing paste to all patients and treated the test group with carboncurettes and Chlorhexidine 0.1% submucosal irrigation withChlorhexidine 1% gel submucosal application, while the control groupreceived submucosal application of Amino acid Glycine powder.
In 5 studies patients have received treatments before their allocationin test and control groups [30,31,36,38,39] while in the remainingprotocols no previous interventions were performed [32-35,37,40,41].
Method of measurementThree of the selected studies [32,34,41] used intraoral radiographs
to evaluate changes in peri-implant marginal bone levels. In one study[40] orthopantomography was used to assess peri-implant marginalbone levels.
In the study by Karring et al. [32] and by Abduljabbar et al. [41]marginal bone changes were calculated as the distance in mm betweenthe bone crest and the most apical bone to implant contact point.
In a similar manner, Renvert et al. [34] calculated the distancebetween a reference points to the deepest point of the bone lesion inmm.
In the study by Arisan et al. [40] the distance in mm betweenimplant shoulder and the bottom of the defect was assessed bycalibrated software.
Study StudyDesign
Case definition Participants Type of Implants Treatments Method ofmeasurement
Results Site andFundings
Buchter etal. [30]
RCTparallel,2GroupsSingle-Blind, 4monthsfollow-up
Chronic peri-implantitis:>50% bone lossaround implants
28 individuals (-0),48 implants Aged:55 Smokingstatus: 32%Smokers,PeriodontalStatus: NA
Type of Implant:ITI, Straumann®
Surface: SLA
Test: Plastic Courettes+Chlorhexidine 0.2%Irrigations+Doxycycline8.5% IrrigationsControl: PlasticCourettes+Chlorhexidine 0.2%irrigationsSupramucosal/gingivalprofessional implant/tooth cleaning withrubber cups andpolishing paste.
PCP 11, 4sites/implant
PPD, PALBOP
NA
Schwarz etal. [31]
RCTparallel,2groups,6monthsfollowup
Probing Depth 4mm inassociation withRX bone loss,BOP or SUP onprobing
20 individuals (-0)32 implants Aged:50 SmokingStatus: NoSmokersPeriodontalStatus: NA
Type of Implant:No CylindricalImplants Surface:17 SLA, 15 TPS
Test: Er:YAG laserControl: PlasticCourettes+Chlorhexidine 0.2%irrigations+Chlorhexidine 0.2%Gel
PCP 12, 6sites/implant
PI, BOP, PPD,MR, CAL
NA
Karring etal. [32]
RCTsplit-mouth,2Groups
BOP, PPD 5 mm,1.5 mm Rxboneloss andexposed implant
11 individuals (-0),2 implants/individual Aged:50-78 SmokingStatus: NA
Type of Implant:Screw-Shaped, 4Br5nemark, 8 ITI,10 Astra Sameimplants/individual
Test: Vector® Control:Carbon CourettesSupramucosal/gingivalprofessional implant/tooth cleaning with
LL 20, 4 sites/implant,Intraoral RX
PL, BOP, PPD,PI, RX bonelevel
NA, Durr Dental
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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Single-Blind, 6monthsfollowup
thread (Mombelliand Lang 1998)
PeriodontalStatus: Exclusionof Chronic SeverePeriodontitis
rubber cups andpolishing paste.
Schwarz etal. [33]
RCTparallel,2Groups,12monthsfollowup
Rx bone loss<30% or >30%.PPD >4 mm,PPd>7 mm atleast in 1 site,BOP/SUP
20 individuals (-0)40 impiants Aged:54 SmokingStatus: NoSmokers,occasionalSmokersPeriodontalStatus: Health/Treated
Type of implant:IMZ "twin plus",ITI, MTX, ZLDuraplant, CamlogSurface: SLA, TPS
Test: Er:YAG laserControl: PlasticCourettes+Chlorhexidine 0.2%irrigations+Chlorhexidine 0.2%Gel
PCP 12, 6sites/implant
PI, BOP, PPD,REC, CAL
Germany,Arbeitsgemeinschaft furKieferchirurgieinnerhalb derDeutschenGesellschaft flirZahn-, Mund- andKieferheilkunde
Renvert etal. [34]
RCTparallel,2groups,6monthsfollowup
Rx bone loss>3mm, PPD>5 mm+BOP/SUP
42 individuals (-0)100 implantsAged: 68 SmokingStatus: NAPeriodontal status:Health/Treated
Surface: 70Machined, 30Medium Rough
Test: Er:YAG laserControl: PERIO-FLOWSupragingival Scalingwith ultrasonic device
Hawe Click-ProbeCalibratedforce 0.2 N 4sites/implant
PPD, BOP,FMPS, PI,intra-oralstandardizedradiograph
Sweden, EMS &KAVO & Philips
Machtei etal. [35]
RCTparallel,2groups,6monthsfollowup
PPD 6-10 mm,positive BOP, Rxbone loss
60 individuals (-4)77 implants Aged:59 SmokingStatus: 38%SmokersPeriodontalStatus: Health/Treated
Surface: no TPSor HA coated
Test: UltrasonicDebridement +matrix0.5 mg CHX Control:Ultrasonic Debridement+matrix gelatine CarbonCourettes+Glycine AirPowder
UNC 15 PPD, BOP,CAL REC
Israel, DexcelPharma
Bassetti etal. [36]
RCTparallel,2groups,12monthsfollow-up
PPD 4-6 mm+BOP, 0.5-2 mmRX bone lossbetweensuprastructureinstallation andpre-screeningappointment.
40 individuals (-1)1 implant/individual, Aged:58 Smokingstatus: NA,PeriodontalStatus: 26subjects withhistory ofperiodontitis
Type of Implant:Titanium screw-shaped Implants,Straumann®Surface: SLA
Test: Photodynamictherapy Control:MinocyclineHydrochlorideMicrospheresSubmucosalmechanicaldebridement withultrasonic scaler
UNC 15Calibratedforce0.15-0.25 N, 6sites/implant,ELISA andPCR
PPD, CALBOP, REC,mPII,MicrobiologicalSample
Switzerland,Bredent MedicalGmbH & Co. KG
RoosJansaker etal. [37]
RCTsplit-mouth,2groups,3monthsfollowup
RX bone loss 2mm, BOP/SUP+,PPD>4 mm
18 individuals (-2)36 implants Aged:72 Smokingstatus: 37,5%Periodontal status:Healthy/Treated
Type of implants: 7ASTRA, 9 NOBEL
Test: Chloramineperisolve+Ultrasonicmechanicaldebridement Control:Ultrasonic mechanicaldebridementSupramucosal/gingivalprofessional implant/tooth cleaning withrubber cups andpolishing paste.
Hawe Click-ProbeCalibratedforce 0.2 N 4sites/implant
FMPS, PI,PPD, CAL BI,BOP
Sweden, RLSGlobal AB
John et al.[38]
RCTparallel,2groups,Single-Blind,12monthsfollow-up
Initial-ModeratePeri-Implantitis:PPD ≥ 4 mm+BOP/SUP, RXbone loss <30%compared to thesituation afterimplantplacement.
32 individuals (-7)36 implants Aged:62 Smokingstatus: non-smokersPeriodontal status:Healthy/Treated
Type of Implant:Screw-typetitanium implants.5 Branemark, 10Camlog ScrewLines® 9 ITI, 2Frialit®, 7 TaperedScrew Vent®, 3 NA
Test: Carbon Courettes+Chlorhexidine 0.1%submucosal irrigation+Chlorhexidine 1% gelsubmucosal applicationControl: AminoacidGlycine Powdersubmucosal applicationSupragingival Scaling
PCP 12, 6sites/implant
PI, BOP, PPD,GR, CAL
Germany, EMS
Gomi et al.[39]
RCTparallel,2Groups,12
Patientscorresponding toCIST class C orD (Lang).
20 individuals (-0),1 implant/individual Aged:68 SmokingStatus: NA
NA Test: Ultrasonic Scalerwith plastic tips+PlasticCourettes+SystemicAzitromicin starting 3days before 500
NA, 6 sites/implant, PCR
PPD, BOP, GI,MicrobiologicalSample, Host-DerivedBiomarkers
Japan, NA
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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monthsfollowup
PeriodontalStatus: ChronicPeriodontitis
mg/day Control:Ultrasonic Scaler withplastic tips+PlasticCourettes
Arisan etal. [40]
RCTsplit-mouth,2groups,6monthsfollowup
BOP/SUP,plaque, pain,4-6mm PPD, <3m of marginalbone loss (MBL)
10 individuals (-0)48 implants Aged:55 SmokingStatus: non-smokersPeriodontalStatus: Healthy
Type of implant:15 MIS, 12CamlogBiotechnologies, 8Nobel Biocare, 7Biohorizons
Test: Plastic Courettes+Diode Laser Control:Plastic Courettes
PQ-OW, 4sites/implant,PCR, OPT
PPD, PI, BOP,MicrobiologicalSample, MBL
Turkey, IstanbulUniversityResearch Fund
Abduljabbar et al. [41]
RCTparallel,2groups,Single-Blind, 6monthsfollowup
BOP on at least30% of theperiimplant sites,PPD 4 mmand/or loss ofsupporting bone(3 mm) around afunctionalimplant
63 individuals (-0)74 implants Aged:41 SmokingStatus: non-smokersPeriodontalStatus: NA
Type of implant:Straumann BoneLevel implants
Test: Plastic Courettes+Nd:YAG laser Control:Plastic Courettes
NA, 6 sites/implant,standardizedradiograph
PPD, BOP/SUP, PI, CBLMicrobiologicalSample, MBL
Saudi ArabiaDeanship ofScientific Researchat King SaudUniversity
Table 2: Variables of study population, study design and comparison were either combined treatments or treatments alone.
Changes in the secondary outcomes were assessed by probing withcalibrated periodontal probes. In two studies the type of periodontalprobe used was not specified [39,40]. Measurements were performedeither at four [30,32,34,37,40] or six sites/implant [31,33,36,38,39,41].
In 3 papers probing was performed with calibrated force rangingfrom 0.15 N to 0.25 N [34,36,37].
Probing pocket depth was assessed in all studies as the distance inmillimetres between the gingival margin and the bottom of the sulcus/pocket. Clinical attachment level was assessed in seven of the selectedstudies [30,31,33,35-38].
While Bassetti et al. [36] and Machtei et al. [35] calculated the CALthe sum of PPD and REC, other authors measured the CAL as thedistance in millimetres from the implant neck to the bottom of thesulcus/pocket.
All of the selected studies evaluated bleeding on probing. Büchter etal. [30], Schwarz et al. [31], Karring et al. [32], Schwarz et al. [33], Johnet al. [38], Gomi et al. [39] and Arisan et al. [40] evaluated if BOP wasevident in the first 30 sec after probing, while Bassetti et al. [36]evaluated the presence of bleeding in the first 10-15 sec after probing.
Four studies [34,35,37,41] evaluated the presence/absence ofbleeding on probing after probing pocket depth assessment. Three[30,31,39] studies don’t specify if they were sponsored. Three[33,40,41] studies received funding from university. The remaining sixgroups [32,34-38] were sponsored by companies of the product tests intheir trials.
Study # 1#Buchter etal. [30]
2#Schwarzet al. [31]
3#Karringet al.[32]
4#Schwarzet al.[33]
5#Renvert etal. [34]
6#Machteiet al. [35]
7#Bassettiet al.[36]
8#Roos-Jansakeret al. [37]
9#John etal. [38]
10#Gomi etal. [39]
11#Minn etal. [40]
12#Abduljabbar etal.[41]
Randomsequencegeneration
"Randomization beingfrom acomputer-generatedtable"
"Randomization wasperformedby cointoss"
"Oneimplantwaschosenatrandom(bychoosinga sealedenvelopeout of abunch of22identicalenvelopes) wastreatedby Vectorsystem,
Thepatientswererandomlyassignedto thefollowingtest andthecontrolgroupsaccording to acomputer-generatedprotocol(Ran d
"Theallocationwascarried outusing acomputersoftwareprogram(SPSS Inc.) for therandomization"
Randomization wasperformedusing acomputer-generatedsequence
Noinformation in thepaper
Therandomizationwas performedwith a randomnumbergenerator,generated byatmospheric noise(http://yeww.random.org).
Noinformation in thepaper
Noinformation in thepaper
Cointoss
"Randomization wasdone, bytossing acoin"
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
Page 7 of 16
J Anesth Clin Res, an open access journalISSN:2155-6148
Volume 9 • Issue 8 • 1000850
while theotherwith submucosaldebridement witha carbonfibrecurettes"
List,DatInfGmbH,Tub-ingen,Germany)"
Allocationconcealment
Noinformationin thepaper
Beforetreatmentthepatientswererandomlyassignedto thetreatmentgroups"
Noinformation in thepaper
Noinformation in thepaper
A cliniciannotinvolvedwith thestudysequencedthe studysubjects tothe therapyallocated.
Eligiblepatients atbaselinevisit wereassignedarandomizationnumberstartingfrom 601.Eachrandomizationnumberwasrandomlyassignedto one ofthe twoletters Aor B; eachletterassignedrandomlyto one ofthe twotreatmentsMatrixC orPerioC.
Noinformation in thepaper
No information inthe paper
Noinformation in thepaper
"Aftertheseinstructional visits,thepatientswererandomlyallocatedto atestgroup(n=10) ora controlgroup(n=10)"
"At thebeginning of thetreatment"
Noinformationin thepaper
Blindingofoutcomeassessment
Nessunainformazionepresentenell'articolo. In unarevision edi Esposito2012: Themeasurements at 18weekswere takenby anothersurgeonthan theone whodid thebaselinemeasurements andthetreatment"
"Allmeasurements weremade atsix aspectsperimplants byoneblindedandpreviouslycalibratedinvestigator"
Thesameinvestigator (ESK)carriedout thetreatment of alltheimplantsandmade alltherecordings atbaselineexamination, whileanotherinvestigator whowasunawareof thetreatmentdeliveredmade allthefollow-uptreatment."
Noinformation in thepaper
Whenperformingtheir studytasks, thestudyexaminer(M. N.) andthetherapist(C. L.)were notjointlypresentwith thestudysubjects.Studysubjectswereinstructednot todiscusstherapywith thestudyexaminer.The studyexaminerwasunaware ofstudytreatmentallocations,
To ensureexamineesblindness,twoseparateinvestigatorsattendedto eachpatient
"Oneblindedandcalibratedexaminerassessed theclinicalparameters atsix sitesperimplant"
No information inthe paper
"Allmeasurementsweremade atsixaspectsperimplantsby oneblindedandpreviouslycalibratedinvestigator"
Noinformation in thepaper
Noinformation in thepaper
"All clinicalandradiographicassessments wereperformedby anexperienced andcalibratedexaminer(TA) whowasblinded tothe studygroups"
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
Page 8 of 16
J Anesth Clin Res, an open access journalISSN:2155-6148
Volume 9 • Issue 8 • 1000850
andperformedall clinicalmeasurements."
Incompleteoutcome data
No Drop-Out
1 patient inthemechanicaldebridement grouphad asevere pusformationand wasmoved inthe lasergroup buttheirresultswere notreported
No Drop-Out
2patientsof themechanicaldebridementgroupwereexcludeddu e toseverepusformationandtreatedwithlaser. Nodataweregiven.
No Drop-Out
Fourpatients,all fromtheMatrixCwereexitedfrom thestudy. Onerequiredextendedantibioticuse (non-related).
1 patientmissedthe 9monthfollow-up butcompleted thestudy, 1patientmissedthe 12monthfollow-up
No information inthe paper
7 patientsdid notcompletethe study,but only 5werereportedas Drop-Out in thetext
No Drop-Out
NoDrop-Out
No Drop-Out
Selectivereporting
Data for allpatientsseem to bereported
Lack ofdata of thepatientexcluded
Lack ofstandarddeviationdata ofthe BOPparameter
Missingdata forthepatientsexcludedby theauthorsandradiographs
Data atpatientlevel notpresented
Data forall patientsseems tobereported
Data forallpatientsseemsto bereported
Data for allpatients seems tobe reported
Lack ofdata of 2patientsexcluded
Data forallpatientsseems tobereported
Data forallpatientsseemsto bereported
Data for allpatientsseems tobereported
Otherbias
Noneapparent
Noneapparent
Noneapparent,sponsored by DurrDental
Noneapparent
Noneapparent,sponsoredby EMS,KAVO
Noneapparent,sponsoredby DexcelPh arma
Noneapparent,sponsored byGmbH &Co.
None apparent,sponsored byRLS Global AB
Noneapparent,sponsoredby EMS
Noneapparent
Noneapparent
Noneapparent
Table 3: Data from the quality assessment.
Interestingly the group of Renvert et al. [34] was sponsored by bothcompanies whose products were compared.
Quality assessmentData from the quality assessment are reported in and in Tables 3
and 4. All studies were considered to have a high risk of bias exceptone, which presents a low risk [35].
Study # 1# 2# 3# 4# 5# 6# 7# 8# 9# 10# 11# 12#
Quality criteria Buchteret al. [30]
Schwarzet al. [31]
Karringet al. [32]
Schwarzet al. [33]
Renvertet al. [34]
Machteiet al. [35]
Bassettiet al. [36]
Roos-Jansakeret al. [37]
Johnet al.[38]
Gomiet al.[39]
Ansanet al.[40]
Abduljabbaret al. [41]
Randomsequencegeneration
+ - ? + + + ? + ? ? - -
Allocationconcealment
? + ? ? ? + ? - ? + + ?
Blinding ofoutcomeassessment
? + + - + + + - + ? - +
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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J Anesth Clin Res, an open access journalISSN:2155-6148
Volume 9 • Issue 8 • 1000850
Incompleteoutcome data
+ - + - + + + - ? + + +
Selectivereporting
+ - - - ? + + + - + + +
Other bias + + + + + + + + + + + +
Total Bias - - - - - + - - - - - -
Table 4: Descriptive analysis of primary variables.
Study outcome, descriptive analysis of primary variables: Amongthe included studies, no implant failures are reported at the end offollow-up. Peri-implantitis recurrence was reported in three studies.The study by Schwarz et al. [33], reported disease recurrence in all thetreated implants at the 6 months follow-up control, so all patients hadto be treated with surgical therapy.
The study by Bassetti et al. [36] reported 5 recurrences, 3 in thecontrol group treated with minocycline and 2 in the test group, treatedwith photodynamic therapy. The study of Renvert et al. [34] reportedthat the 11% of the patients in the test and in the control group stillpresented pus on probing.
Only one of the selected studies Gomi et al. [39] reported 11complications, 10 made up analgesic administration to treat pain givenby non-surgical procedures and 1 case of diarrhoea following theconsumption of azithromycin. Four trials [32,34,40,41] reported thechanges in radiographic bone level.
The group of Renvert [34], instead, found a mean difference of 0.3 ±0.9 mm in the laser group and of 0.1 ± 0.8 mm in the air-flow group,failing to found a clinical relevance in this outcome.
In the study by Arisan et al. [40] statistically significant mean bonechanges were found in both groups between baseline and the 6 months
follow-up (F=38.34, p<0.0001). A statistically significant difference wasfound also comparing the test and control groups at the end of thefollow-up period (0.5227 mm, adjusted p=0.0013) in favour of the lasergroup.
The group of Karring et al. [32] showed no statistical significantdifferences between baseline and the 6- month control regarding bonechanges, neither within each treatment group nor between treatments,with a difference, after 6 months, of -0.3 ± 1 mm in test group and -0.3± 0.8 mm in control group.
In the study of Abduljabbar et al. [41] at baseline and at 6-monthfollow-up, the mean crestal bone loss was comparable amongindividuals in groups 1 and 2, with a base-line 1.8 mm of mean lossand 1.7 mm at the follow-up in group 1 and 2.1 mm of mean crestalbone loss at the base-line, that change in 2.2 mm at follow-up in group2.
Study outcome, descriptive analysis of the changes in probingpocket depth: Data about secondary outcomes are presented in Tables5 (PPD), 6 (CAL) and 7 (BOP).
Study Intervention/ControlMeasurementMethod Test Difference
ControlDifference Difference P value
Büchter etal. [30]
Test: Plastic Courettes+Chlorhexidine 0.2% Irrigations+Doxycycline 8.5% Irrigations Control: Plastic Courettes+Chlorhexidine 0.2% irrigations Supramucosal/gingivalprofessional implant/tooth cleaning with rubber cupsand polishing paste.
PCP 11,4 Sites/implant 1.15 ± 0.23 mm 0.56 ± 0.30 mm 0.59 ± 0.53 mm 0.046
Schwarz etal. [31]
Test: Er:YAG laserControl: Plastic Courettes+Chlorhexidine 0.2%
PCP 12,6 Sites/implant 0.8 ± 0.1 mm 0.6 ± 0.1 mm 0.2 ± 0.2 mm <0.001
Karring etal. [32]
Test: Vector®Control: Carbon Courettes Supramucosal/gingivalprofessional implant/tooth cleaning with rubber cupsand polishing paste.
LL 20,4 Sites/implant 0 ± 0.1 mm 0.1 ± 0.6 mm 0.1 ± 0.7 mm >0.1
Schwarz etal. [33]
Test: Er:YAG laserControl: Plastic Courettes+Chlorhexidine 0.2%Irrigations+Chlorhexidine 0.2% Gel
PCP 12,6 Sites/implant 0.33 ± 2.3 mm 0 ± 2.64 mm 0 ± 3.22 mm <0.05
Renvert etal. [34]
Test: Er:YAG laserControl: PERIO-FLOWSupragingival Scaling with ultrasonic device
Hawe Click-ProbeCalibrated force 0.2 N4 Sites/implant 0.8 ± 0.5 mm 0.9 ± 0.8 mm 0.1 ± 1.3 mm P=0.55
Machtei etal. [35]
Test: Ultrasonic Debridement+matrix 0.5 mg CHXControl: Ultrasonic Debridement+matrix gelatinCarbon Courettes+Glycine Air Powder UNC 15 2.13 ± 0.22 mm 1.73 ± 0.19 mm 0.40 ± 0.31 mm 0.178
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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Volume 9 • Issue 8 • 1000850
Bassetti etal. [36]
Test: Photodynamic therapy Control: MinocyclineHydrochloride Microspheres Supramucosal/gingivalprofessional implant/tooth cleaning with rubber cupsand polishing paste.
UNC 15 Calibratedforce 0.15 N-0.25 N6 Sites/implant 0.36 ± 0.03 mm 0.49 ± 0.01 mm 0.07 ± 0.04 mm >0.05
John et al.[38]
Test: Carbon Courettes+Chlorhexidine 0.1%Submucosal irrigation+Chlorhexidine 1% gelsubmucosal applicationControl: Aminoacid Glycine Powder Submucosalapplication Supragingival Scaling.
PCP 12,6 Sites/implant 0.5 ± 0.9 mm 0.4 ± 0.9 mm 0.1 ± 1.8 mm >0.05
Gomi et al.[39]
Test: Ultrasonic Scaler with plastic tips+PlasticCourettes+Systemic Azithromycin starting 3 daysbefore 500 mg/dayControl: Ultrasonic Scaler with plastic tips+PlasticCourettes
NA,6 Sites/implant 1.19 ± 0.39 mm 0.23 ± 0.01 mm 0.96 ± 0.4 mm 0.01
Arisan et al.[40]
Test: Plastic Courettes+Diode LaserControl: Plastic Courettes
PQ-OW,4 Sites/implant 0.17 ± 1.41 mm 0.21 ± 0.83 mm 0.04 ± 2.24 mm <0.001
Table 5: Differences in PPD between baseline and the end of the investigation for test and control groups.
In the study conducted by Büchter et al. [30] treatment in the testgroup was performed using plastic courettes in association withChlorhexidine 0.2% and Doxycycline 8.5% irrigations whilst in thecontrol group plastic courettes with Chlorhexidine 0.2% irrigationswere employed.
Between the start and the end the test group showed a mean PPDreduction of 1.15 ± 0.23 mm, while in the control group was 0.56 ±0.30 mm, with a statistically significant difference between groups of0.59 ± 0.53 mm (p=0.046).
In the study by Schwarz et al. [31] all the patients were initiallytreated with supramucosal/gingival professional implant/toothcleaning with rubber cups and polishing paste. The test group wastreated with Er:YAG laser, and the control group with plastic courettesin association with 0.2% chlorhexidine irrigations and gel.
The difference of PPD between baseline and 12 months follow-up inthe test group was 0.8 ± 0.1 mm, and 0.6 ± 0.1 mm in the controlgroup. A statistically significant difference between groups of 0.2 ± 0.2mm was found (p<0.001).
Karring et al. [32] performed a split-mouth study comparing theVector® system in the test group with carbon courettes in the controlgroup, finding a difference of 0 ± 0.1 mm and 0.1 ± 0.6 mmrespectively. No significant differences between group could be found(0.1 ± 0.7 mm, p>0.1).
In another study, Bassetti et al. [36] used carbon courettes andGlycine air powder on all patients. In this protocol, photodynamictherapy (test) and Minocycline Hydrochloride microspheres (control)were compared. The Authors found a difference of 0.36 ± 0.03 mm and0.49 ± 0.01 mm, respectively. There was a difference of 0.07 ± 0.04 mmbetween groups with a p value>0.05.
Schwarz et al. [33] evaluated the efficacy of Er:YAG laser, comparedto plastic courettes, 0.2% chlorhexidine irrigations and the use of 0.2%chlorhexidine gel. They found a difference between baseline and 12months follow-up amounting to 0.33± 2.3 mm in the test group and 0± 2.64 mm in the control group. Mean inter-group differences were 0 ±3.22 mm.
Renvert et al. [34] analyzed the effect of Er:YAG laser in comparisonto Perioflow. They found a PPD reduction of 2.13 ± 0.22 mm in the test
group and 1.73 ± 0.19 mm in the control group. The inter-groupdifference amounted to 0.40 ± 0.31 mm. No statistical differences arereported between baseline and 6 months follow-up.
Machtei et al. [35] studied the efficacy of the association ofultrasonic debridement and a matrix containing 0.5 mg ofchlorhexidine compared to the association of ultrasonic debridementand a gelatin matrix. The test group showed a reduction of 2.13 ± 0.22mm, while the control groups a reduction of 1.73 ± 0.19 mm. Theinter-group difference amounted to 0.40 ± 0.31 mm. No statisticaldifferences could be found.
John et al. [38] performed a study in which given supramucosal/gingival professional implant/tooth cleaning with rubber cups andpolishing paste to all patients and treated the test group with carboncurettes and Chlorhexidine 0.1% submucosal irrigation withChlorhexidine 1% gel submucosal application, while the control groupreceived submucosal application of Amino acid Glycine powder.Differences were of 0.5 ± 0.9 mm in the test group, 0.4 ± 0.9 mm in thecontrol group, 0.1 ± 1.8 mm between groups and P value was >0.05.
In the study included by Gomi et al. [39], all patients receivedSupragingival Scaling using ultrasonic scaler with plastic tips andplastic courettes. In the test group systemic subministration of 500mg/day of Azithromycin was performed, starting 3 days before. Thecontrol group was treated with mechanical debridement alone. Therewas a difference of PPD of 1.19 ± 0.39 mm in the test group, 0.23 ±0.01 mm in the control group and 0.96 ± 0.4 mm between groups, witha p value of 0.01.
Arisan et al. [40] performed a study in which the test group wastreated with plastic courettes plus one application of diode laser, whilein the control group only plastic courettes were employed.
A mean PPD reduction of 0.17 ± 0.41 mm was found in the testgroup, and of 0.21 ± 0.83 mm in the control group. Between test andcontrol group there was a difference of 0.04 ± 2.41 mm with a p value<0.001.
Study outcome, descriptive analysis of the changes in clinicalattachment level: Only six of the selected studies reported clinicalattachment level values and in one of them [36] the method ofmeasurement was not clear.
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
Page 11 of 16
J Anesth Clin Res, an open access journalISSN:2155-6148
Volume 9 • Issue 8 • 1000850
The largest reduction in CAL was found by Machtei et al. [35] with amean value of 2.21 ± 0.23 mm in the test group and 1.56 ± 0.25 mm inthe control group. The difference between groups was statisticallysignificant and amounted to 0.65 ± 0.34 mm (P=0.05).
Instead, Bassetti et al. [36] found the lowest mean CAL reductionwith an average value of 0.16 ± 0.04 in the test group, 0.19 ± 0.07 mmin the control group and a difference between groups of 0.03 ± 0.11mm.
In this protocol no statistically significant differences betweengroups could be found at the end of the follow-up period (P>0.05). Thestudy by Büchter et al. [30] reported a gain of 1.15 ± 0.03 mm in thetest group using plastic courettes, submucosal irrigations of 0%, 2%chlorhexidine and 8,5 doxycycline, and a gain of 0.33 ± 0.06 mm in thecontrol group using plastic courettes and submucosal irrigations with0%, 2% chlorhexidine. The inter group difference was statisticallysignificant (P=0.024) and amounted to 0.82 ± 0.09 mm.
Schwarz et al. [31] reported a mean gain of 0.6 ± 0.1 mm in the testgroup and 0.7 ± 0 mm in the control group, with a difference of 0.1 ±0.1 mm between groups (P>0.05). In a another study Schwarz et al.[33] found a gain in CAL of 0.25 ± 2 mm in the test group and 0.15 ±2.2 mm in the control group with a mean intergroup difference of 0.1 ±2.1 mm employing the same treatment modalities.
John et al. [38] reported a gain of 0.5 ± 1.1 mm and 0.6 ± 1.3 mm inthe test and control groups respectively, with a non-significantdifference between groups amounting to 0.1 ± 0.3 mm (P>0.05).
Study outcome, descriptive analysis of the changes in bleeding onprobing: All the included studies reported the BOP outcome. Four ofthe selected papers [31,32,40,41] didn’t report standard deviations forthis parameter so were not included in the resuming Table 7.
Büchter et al. [30] reported a mean reduction of 0.27 ± 0.01 in thetest group and of 0.13 ± 0.01 in the control group, with a difference of0.14 ± 0.02 between groups and a significant P value of 0.01.
Schwarz et al. [33] found a reduction of 45.83 ± 38.7 in the testgroup and 25.33 ± 22.6 in the control group, with an inter-groupdifference of 16 ± 30.7 (P<0.01).
In the study by Bassetti et al. [36] a reduction of 2.52 ± 0.25 wasfound in the test group while the control group showed a reduction of2.31 ± 0.08, with a difference between groups amounting to 0.21 ± 0.33and a statistically considerable P value (<0.05).
Machtei et al. [35] found a reduction of 57.5 ± 7.92 with ultrasonicdebridement and a matrix containing 0.5 mg of chlorhexidine and areduction of 45.5 ± 8.8 using ultrasonic debridement and a matrixgelatin. The inter-group difference was 12.1 ± 6.7 in favor of the testgroup but no statistically significant differences could be foundbetween groups (P=0.3125).
John et al. [38] reported a mean reduction value of 41.2 ± 29.5 in thecontrol group, 16.6 ± 33.4 in the test group, with an relevant differenceof 24.6 ± 63.9 and a P value <0.05.
In the study by Gomi et al. [39] a reduction of 24.5 ± 3.9 was foundin the test group and of 6.1 ± 1.5 in the control group, setting adifference between groups of 18.4 ± 5.4 with a very low P value(<0.001).
In a more recent study, Jansaker et al. [37] reported a meanreduction of 0.67 ± 0.58 in the test group, which was treated with theassociation of ultrasonic mechanical debridement and chloramine
perisolve and a decrease of 0.64 ± 0.54 in the control group usingmechanical debridement alone. An inter-group difference of 0.03 ±1.12 was found (P=0.001).
DiscussionThe limitations of the present review consist in the paucity of
available data and reliable data from studies included. In fact we founda great heterogeneity in the protocols utilized, indeed they haveevaluated different endpoints with different follow-up and most of thestudies have a high risk of bias.
Non-surgical therapy of peri-implantitis has the primary aim todecontaminate implant surface by the bacterial biofilm, which canreduce implant failure, disease recurrence and parameters such asclinical attachment level, probing pocket depth and bleeding onprobing, possibly without causing side effects to the patient. Thissystematic review was conducted to evaluate the present literature andto provide scientific evidence on the existing RCTs evaluating differenttherapeutic protocols for non-surgical treatment of peri-implantitis.
The primary endpoints selected were implant failure, changes inradiographic marginal bone level, presence of complications andrecurrence of peri-implantitis while the secondary variables were thechange in probing pocket depth, gains in clinical attachment level andreduction of bleeding on probing.
In none of the included studies implant failure was adopted as aprimary variable, but Authors reported data about this parameter.Among the papers included in the present review, no implant failurewas reported at the end of the follow-up period.
Disease recurrence was reported in three trials. In particular,Bassetti et al. [36] reported disease recurrence in 5 of the 39 includedimplants, treated either with photodynamic therapy or with theapplication of minocycline microspheres. In a previous trial [33], thetest group was treated with Er:YAG laser and the control group withsubgingival manual debridement. After six months, the Authors founddeterioration in clinical parameters of all patients and had to re-treatthe patients and performed bone augmentation procedures.
In another trial in which Er:YAG laser and air-abrasives wereemployed [34] after six months of follow-up, 11% of the patients in thetest and in the control group still presented pus on probing.
These data underline the fact that in short-term evaluation, poorconclusions can be drawn on the efficacy of non-surgical therapy ofperi-implantitis to arrest disease progression and stabilize clinicalparameters. Studies with longer follow-up are needed.
Moreover, in some of the studies included in this systematic review,treatments were performed only one time, while in other papers thetherapies were applied multiple times so the effect of repeated-application versus single application of therapies needs to be furtherinvestigated.
One paper reported about complications related to treatments. Inthis study, systemic Azithromycin in association to subgingivaldebridement was administered to test group patients, while in thecontrol group only subgingival debridement was performed. Themajority of complications consisted in pain related to mechanicaltherapy (10 subjects from both groups) that was controlled with theadministration of analgesics, and only one patient in the test grouppresented diarrhoea.
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
Page 12 of 16
J Anesth Clin Res, an open access journalISSN:2155-6148
Volume 9 • Issue 8 • 1000850
Among the included studies, four trials [32,34,40,41] reported aboutradiographic bone changes before and after therapy. The authors wereunable to find clinically significant differences both in the test and inthe control group between baseline and the end of the study.
There is a general tendency toward better results when treatmentcombinations are performed for non-surgical mechanical therapies in
terms of PPD reduction (Table 5) and CAL gain (Table 6). These resultsare in agreement with a recent systematic review by Faggion et al. [42],also assessing the influence of additional treatments in association withmechanical debridement alone for non-surgical therapy of peri-implantitis.
Study Intervention/Control Measurement Method Test Control Difference P value
Büchter et al.[30]
Test: Plastic Courettes+Chlorhexidine 0.2%Irrigations+Doxycycline 8.5% IrrigationsControl: Plastic Courettes+Chlorhexidine0.2% irrigations Supramucosal/gingivalprofessional implant/tooth cleaning withrubber cups and polishing paste.
Distance from theimplant shoulder to thebottom of the peri-implant pocket4 Sites/implant
1.15 ± 0.03 mm 0.33 ± 0.06 mm 0.82 ± 0.09 mm 0.024
Schwarz et al.[31]
Test: Er:YAG laserControl: Plastic Courettes + Chlorhexidine0.2% Supramucosal/gingival professionalimplant/tooth cleaning with rubber cups andpolishing paste.
From the implant neck tothe bottom of theprobable sulcus6 Sites/implant
0.6 ± 0.1 mm 0.7 ± 0 mm 0.1 ± 0.1 mm >0.05
Schwarz et al.[33]
Test: Er:YAG laserControl: Plastic Courettes+Chlorhexidine0.2% Irrigations+Chlorhexidine 0.2% GelSupragingival Scaling with Ultrasonic device
From the implant neck tothe bottom of theprobeable sulcus6 Sites/implant
0.25 ± 2 mm 0.15 ± 2.2 mm 0.1 ± 2.1 mm p>0.05
Machtei et al.[35]
Test: Ultrasonic Debridement+matrix 0.5 mgCHXControl: Ultrasonic Debridement+matrixgelatinCarbon Courettes+Glycine Air Powder
PD+GR 2.21 ± 0.23 mm 1.56 ± 0.25 mm 0.65 ± 0.34 mm P=0.05
Bassetti et al.[36]
Test: Photodynamic therapy Control:Minocycline Hydrochloride MicrospheresSupramucosal/gingival professional implant/tooth cleaning with rubber cups andpolishing paste.
NA6 Sites/implant
0.16 ± 0.04 mm 0.19 ± 0.07 mm 0.03 ± 0.11 mm >0.05
John et al. [38] Test: Carbon Courettes+Chlorhexidine 0.1%Submucosal irrigation+Chlorhexidine 1% gelsubmucosal applicationControl: Aminoacid Glycine PowderSubmucosal application
From the implant neck tothe bottom of theprobeable Pocket6 Sites/implant
0.5 ± 1.1 mm 0.6 ± 1.3 mm 0.1 ± 0.3 mm >0.05
Table 6: There is a general tendency toward better results when treatment combinations are performed for non-surgical mechanical therapies interms of PPD reduction and CAL gain.
However, these data must be carefully evaluated, because all exceptone of the included studies [35] presented a high risk of bias.
Among the different treatment combinations, it seems that theassociation of mechanical debridement and local antiseptics can bringto better clinical results.
Data by Machtei et al. [35] show reduction of 0.40 ± 0.31 mmgreater in PPD when a 0.5 mg chlorhexidine matrix is associated tomechanical debridement with an ultrasonic device compared with thecontrol group in which a gelatin matrix was employed with mechanicaldebridement.
The study of Gomi et al. [39] is the only study in which systemicantibiotics were employed. The greater results in PPD reduction (1.19± 0.39 mm of reduction in the test group and 0.23 ± 0.01 mm in thecontrol group) if compared with topic antibiotics agents, can beexplained by the difference in drugs administration. In fact, while withtopic agent’s higher concentrations of the drug can be reached in apocket; the crevicular fluid is able to wash it out rapidly, asdemonstrated in the study by Goodson et al. [43].
Instead, using systemic antibiotics agents is possible to obtain lowerconcentrations in a periodontal/peri-implant pocket, but a continuousdrug delivery.
These data have to be evaluated taking into account that studiespresented different methods of implant surface decontamination anddifferent combinations of treatments. When further interpreting theresults of the qualitative analysis, it could be also noted thatcombination of treatments result in greater reductions of BOP.Decrease in this parameter could be seen both in test and controlgroups, but the test groups showed statistically greater improvementthan the controls. Only six of the selected studies reported data onClinical Attachment Level changes from baseline to the end of thefollow-up period.
In terms of CAL gain, it seems that the use of antiseptic agents inassociation to mechanical therapy is able to provide better results. Inparticular, Machtei et al. [35] found a statistically significant greaterCAL gain of 0.65 ± 0.34 mm better in the test group, when 0.5 mgchlorhexidine matrix is associated to mechanical debridement.
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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Study Intervention/Control Measurement Method Test Control Difference P value
Büchter etal. [30]
Test: Plastic Courettes+Chlorhexidine 0.2% Irrigations+Doxycycline 8.5% Irrigations Control: Plastic Courettes+Chlorhexidine 0.2% irrigations Supramucosal/gingivalprofessional implant/tooth cleaning with rubber cups andpolishing paste.
Presence of bleeding within 30 safter the pocket had been probedwith a periodontal probe, 4 Sites/implant
0.27 ±0.01
0.13 ±0.01
0.14 ± 0.02 0.01
Schwarz etal. [33]
Test: Er:YAG laserControl: Plastic Courettes+Chlorhexidine 0.2% Irrigations+Chlorhexidine 0.2% Gel Supragingival Scaling withUltrasonic device
Presence if bleeding was evidentwithin 30 s after probing, orabsent, if no bleeding was noticedwithin 30 s after probing,6 Sites/implant
45.83 ±38.7
25.33 ±22.6
16 ± 30.7 p<0.01
Machtei etal. [35]
Test: Ultrasonic Debridement+matrix 0.5 mg CHXControl: Ultrasonic Debridement+matrix gelatine CarbonCourettes+Glycine Air Powder
NA 57.5 ±7.92
45.5 ± 8.8 12.1 ± 6.7 P=0.3125
Bassetti etal. [36]
Test: Photodynamic therapy Control: MinocyclineHydrochloride Microspheres Supramucosal mechanicaldebridement with Ultrasonic Scaler
Presence of bleeding within 10-15s after the pocket had beenprobed with a periodontal probe,6 Sites/implant
2.52 ±0.25
2.31 ±0.08
0.21 ± 0.33 <0.05
Jansaker etal. [37]
Test: Chloramine perisolve+Ultrasonic mechanicaldebridementControl: Ultrasonic mechanical debridement Supramucosal/gingival professional implant/tooth cleaning with rubbercups and polishing paste.
Presence of bleeding4 Sites/implant
0.67 ±0.58
0.64 ±0.54
0.03 ± 1.12 P=0.001
John et al.[38]
Test: Carbon Courettes+ hlorhexidine 0.1% Submucosalirrigation+Chlorhexidine 1% gel submucosal applicationControl: Aminoacid Glycine Powder Submucosal applicationSupra gingival Scaling
Present if bleeding was evidentwithin 30 s after probing, orabsent, if no bleeding was noticedwithin 30 s after probing,6 Sites/implant
16.6 ±33.4
41.2 ±29.5
24.6 ± 63.9 <0.05
Gomi et al.[39]
Test: Ultrasonic Scaler with plastic tips+Plastic Courettes+Systemic Azithromycin starting 3 days before 500 mg/dayControl: Ultrasonic Scaler with plastic tips+Plastic Courettes
Scored positive if bleeding wasvisible within 30 s after probing,6 Sites/implant
24.5 ±3.9
6.1 ± 1.5 18.4 ± 5.4 <0.001
Table 7: Descriptive analysis of the changes in bleeding on probing.
The other studies reporting on CAL changes were unable to findstatistically significant differences between test and control groups.
In general, there is a lack of consistency of data and this could bedue to the following factors:
1. Although all the included studies are RCTs on non-surgicaltreatment of peri-implantitis, a high heterogeneity in study nature andconcept can be seen. In some protocols, the application of treatmentwas performed one time, while other RCTs are based on repeatedapplications. Combination of treatments is based on the association ofdifferent mechanical and chemical agents. Since most of the trials arebased on the association of different treatments, it is difficult todiscriminate which can be the most effective.
2. RCTs included are different in their design, either split-mouth orparallel groups design.
3. There is a lack of standardization in the control groups. Thismeans that nowadays no gold-standard therapy is established for non-surgical treatment of peri-implantitis. Often, the same therapies areused both as a test or a control group. Furthermore comparisonsbetween completely different types of interventions are made.
These problems were treated in a recent systematic review in whichthe authors pointed out that the quality of evidence on peri-implantitisis low, even if the most recent publications show a higher level ofreport [44].
Even if statistically significant improvements in clinical parameterscan be found with the different treatments alone or in combination,one may argue if these results are clinically significant. Within thelimitations of the present systematic review, it seems that combinationsof treatments result in a greater reduction in PPD when compared withtreatments alone.
In order to better define which therapy can provide better clinicaloutcomes, researches should follow some important features. First ofall therapies should be defined and clearly distinguished for test group,while control group should not receive any adjunctive treatment. Thisis because no gold-standard therapy is now eligible for peri-implantitis.The sample of population should be well described reporting dataabout sex, age and ethnicity and about risk factors such as smoke anddiabetes. Number and type of implants per patient and their sitesshould be reported for each group involved. The same trained assessorshould measure the outcome variables and the methods of recordingand then register measurements over time, detailing every interventionor drop out. Follow-up measurements should continue every twomonths for at least 12 months, conforming to set methods.
ConclusionNon-surgical therapy of peri-implantitis seems to have a limited
efficacy. The association of mechanical debridement and adjunctivemeasures seems to provide slightly greater benefits. In particular theuse of systemic azithromycin associated to mechanical debridement
Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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J Anesth Clin Res, an open access journalISSN:2155-6148
Volume 9 • Issue 8 • 1000850
can give better clinical outcomes; indeed in the study of Gomi et al.[39] was reported a greater reduction of 0.96 ± 0.4 mm in the testgroup compared with the data of the control group after 1 year offollow up.
Clinical trials on this topic are characterized by a greatheterogeneity and nowadays there is no gold-standard therapy that canbe used as control. Better and standard designed clinical trials and withlonger follow-up are needed.
Conflict of Interest NotificationThe authors declare no conflict of interest concerning the contents
of the study. The study was self-founded by the authors.
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Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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Citation: Giacomo P, Gian S, Riccardo B, Maurizio S, Cesare P (2018) Non-surgical Treatment of Peri-implantitis: A Systematic Review of theLiterature. J Anesth Clin Res 9: 850. doi:10.4172/2155-6148.1000850
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